Shawn Judson, Ed.D

     Board of Trustees

Superintendent

Douglas M. Claflin

     Brynna Cadman

Assistant Superintendent of Business Services

     Robert Garcia

Terry Embleton

     Dayna Karsch

Assistant Superintendent of Personnel Services

     David W. Long

Charlayne Sprague

     Mondi M. Taylor

Assistant Superintendent of Instruction/Pupil Services

 
 

1883

 
 

6061 East Avenue, Etiwanda, California 91739

 

www.etiwanda.k12.ca.us

 

(909) 899-2451     FAX (909) 803-3033

 

APPROVAL REQUEST FOR PROGRAMS / ACTIVITIES

FOR BEFORE, DURING & AFTER-SCHOOL PROGRAMS

PLEASE SUBMIT REQUEST 2 WEEKS PRIOR TO THE EVENT

School:

Grade: 

Program/Activity (provide description):

Location:  

Date (s):         To    

Time (s):    :      To     :

Vendors / Props / Equipment / Other:  

Proof of Insurance – (select one):

This is a school/site sponsored program. The Etiwanda School District will provide insurance.

School sponsored programs involving vendor participation will require, of each vendor, a
      certificate of liability insurance (
Please see the insurance coverage matrix determine specific liability insurance coverage).

1.The Contractor shall provide and maintain liability insurance and to issue to both the ETIWANDA SCHOOL DISTRICT and CALIFORNIA SCHOOLS RISK MANAGEMENT a valid and current Certificate of Insurance naming the DISTRICT as additional insured. (BP 3312)

2.Insurance Requirements

The certificate holder shall be Etiwanda School District 6061 East Avenue, Etiwanda, CA 91739

Etiwanda School District and California Schools Risk Management to be
      named as additional insured

The Description of Operations information must be completed

When the named consultant/lecturer/presenter, or any person in their employment, will have or has the potential to have unsupervised contact with students, FINGERPRINT CLEARANCE IS REQUIRED. Please contact the Business Services Department for the necessary paperwork.

IMPORTANT REMINDER: If the activity involves a field trip, you must complete the FieldTrip Checklist, which includes directions regarding emergency Epipens.

Signature of Principal

 

Date

This is a PTA or PTO sponsored program. The PTA or PTO will carry all liability insurance coverage.
      A copy of the current PTA/PTO certificate of insurance, naming the ESD as Additional Insured, shall
      be forwarded to the ESD Risk Services Department.

Signature of PTA/PTO President

 

Date

For assistance regarding insurance information, please contact Renee Peccoralo at (909) 803-3132.

Updated July 2015 Forms/ProgramActivities/Master.doc